Nicaragua Program Details

The program integrates TFH’s core methodologies into intake workshops for new “health promoters”, regular continuing education, monthly meetings, and periodic special trainings and campaigns. The longitudinal components of the program are focused on community diagnosis and action planning (CDAP) and training on resource mapping and linkage, encompassing several subprojects and programs.  Resource mapping involves working to identify and map resources (physical, human resources, organizations, etc.), link existing resources, and bring new resources to participating communities.  Community diagnosis pairs training with direct action, starting with health promoters developing and enacting health promotion goals, working in teams to develop larger programs within communities, and finally acting as a cohesive program on a regional campaign to improve health, environment and livelihood in the rural communities of San Ramón.  Incentives in the form of scholarships, paid internships, and additional training opportunities are being developed as part of the basic infrastructure of the program.  Assessment and evaluation are integrated into the program as a whole, and opportunities for students from Universities in Nicaragua and abroad to become involved in service and research on empowerment, cost-effectiveness and health promotion are emphasized as a secondary goal.

TFH traveled to Nicaragua in December 2009 to conduct its first new intake workshop, graduating 17 promoters, in December 2009.  In Summer 2010, TFH conducted a new intake workshop graduating 28 new promoters, a program planning workshop for old promoters, a Continuing Education Workshop on domestic violence, family planning and reproductive health, respiratory health, and Community Diagnosis Level 2, qualitative research on family planning and domestic violence, and hiring 2 Program Assistants.  In December 2010, TFH conducted a Continuing Education workshop on action planning and first aid, and provided further training for the Program Assistants.

Intake Workshops

Community-selected individuals are trained in a highly interactive 2-week intake workshop as “health promoters” to address common health problems in their community, with an emphasis on leadership and program planning.  TFH, local partners, and the health promoters themselves facilitate the workshops.  Starting with this initial training, health promoters will learn to identify problems in their home communities and plan cost-effective responses that can address these problems. After this initial training, health promoters return to their home communities to implement these programs, with centralized follow-up monthly meetings to provide feedback on support for projects, facilitate health promoter exchange of ideas, networking between communities, and continuing education.  New intake workshops are held 1 to 2 times per year and include up to 30 new health promoters.  Thus far, 2 cohorts (43 promoters) have been trained.  Promoters work in teams in their community, with a goal of at least one female and one male volunteer health promoter in each village and as many as 1 health promoter per 25 households (with health promoter teams of up to 7 in larger communities).

Continuing education and monthly meetings

At least 2 continuing education workshops are provided annually on topics of the promoters’ choosing and from input from local partners.  Promoters attend monthly meetings in San Ramón, facilitated by the promoters, program staff and representatives from partner agencies.  Some of the monthly meetings are replaced by visits to communities where promoters have been successful in developing programs or trainings on specific topics.

8 monthly meetings were held in 2010 and 2 thus far in 2011. Successes at monthly meetings include presentations by health promoters on their Level II CDAP projects and a visit to a promoter’s village who had set up a daycare including an educational component during coffee farming season for her community.  Outside presenters have come to give presentations, the program assistants have developed exercises on leadership, and a health promoter has taught her methods of community mapping to the rest of the group.

Scope of Practice

The scope of practice of health promoters is defined in consultation with the promoters themselves, the Ministry of Health, Mayor’s Office, local Fire Department, international standards, and best practice, and includes health education, advocacy, community assessment, program planning, problem solving, community mobilization, screening, first aid, and referral to higher levels of care or appropriate resources.  Although some are trained separately by the government to provide basic health care, the health promoter should not be considered a health care provider as such.

Community diagnosis and resource mapping

Health promoters are involved in longitudinal community mapping, resource identification, and community diagnosis projects. The first level of community diagnosis consists of using knowledge learned in training and community assessment activities to develop actionable goals to tackle a health challenge in their community using existing resources. The primary goals and work plans for Level 1 Community Diagnosis have a six-month to 1 year duration, and are designed to provide self-reinforcing successes, allowing the promoter to begin working in teams on a larger community diagnosis project in their village. The majority of the promoters are in the Action Planning and Implementation half of CDAP Level II while approximately a quarter of the promoters are ready to begin CDAP Level 3.

Program assistant positions

2 rotating 12-month “Program Assistant” positions are offered within the health promoter program to ensure self-management and improved capacity building.  They are a structured work / study opportunity designed to simultaneously provide local management and concerted training in program administration.  Program assistants conduct several rounds of community visits annually, organize monthly meetings, attend and participate in meetings with partnering organizations, maintain program records, maintain the health education library, participate in evaluation, and compile monthly reports.

Promoter Program Planning Workshops

These meetings serve several purposes: They promote development of meaningful ownership of the program by its participants, the health promoters, for reasons of working towards sustainability and because it is the right thing to do.  They also serve an educational purpose integrating the community engagement methodologies being measured that attempt stimulate empowerment, in this case of the promoters and the program itself.

Program Director’s Progress Note – CDAP Successes

Health promoters are broadening their view of their communities and working with community leaders in order to identify truly community-driven areas for improvement. Though many promoters are just beginning this lengthy process, there are a few who have already made impressive positive changes that impact the health of their entire community.

One such promoter is Ana Auxiliadora Mairena from the community of Los Andes. She collaborated with 2 different organizations to provide daycare during the 3 month coffee harvest season for those children who would otherwise have been left at home while their parents and older siblings were out harvesting. This daycare, called ”Coffee Camp,” provided food, shelter and educational games to children ranging in age from 6 months to 13 years, and would not have been possible without Ana’s initiative and dedication to her community. She hopes to be able to provide this same service to her community in the years to come.

Perhaps the most common promoter driven community projects have come in the form of recurring large scale community clean-ups and the coordination of trash disposal. Many of the health promoters have made drastic improvements in their community’s cleanliness and waste management practices through these efforts.

In preparation for this summer’s workshops, the promoters are creating community maps that will include land and general layout (rivers, high and low points, streets, foot paths, bridges, foot bridges, neighboring communities, approximate number of inhabitants, and the locations of cesspools and mines), and buildings (churches, schools, clinics, stores/markets, community centers and other meeting places, permanent homes and temporary housing for harvest seasons). These basic maps will be used as the foundation from which specific community health issues, such as access to clean water and location of water sources and latrines, can be mapped. This type of targeted mapping will be incorporated into the summer workshop as part of the community diagnosis training. If successful, these maps could prove extremely useful to the promoters in assessing and addressing a variety of community identified health issues.

As part of the program planning process, promoters have identified their own goals, guiding values (which operate internally, with their work in the community, and in their interaction with TFH), name, logo and some program evaluation indicators.  Values identified included trust and respect; availability; communication; community, unity, and solidarity; responsibility; willingness and mutual support; health; and equality.  Promoters voted on their logos and names at a monthly meeting.  The winner was chosen as the initial identifier of the program, and the runners-up will be used on t-shirts and promotional materials sold by the program.

Assessment and Research

• Iterative Community Health Assessment (2 stages, an initial census and a promoter implemented community health assessment in approximately 10 communities, are already complete)
• Phase I: Demographic and Health Census of La Pita, limited regional health assessment (2008-2009)
• Phase II: Demographic and Health Assessment led by promoters (2010)
• Phase III: Community mapping è Randomized Phase III CDAP Outcome Studies (2012-2014)
• Qualitative Research on Promoter-Identified Topics
•  Domestic violence: Katie Pope
• Barriers to Accessing Family Planning –  Kathy Hamlin, and Sirina Keesara
• Workshop evaluation
• Organizational Ethnography
• Pending: Empowerment research (longitudinal promoter surveys, triangulation